§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.
§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.
§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
|
Observations:
Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the resident record was complete and accurately documented for one of four residents reviewed (Resident 1).
Findings include:
Review of facility policy, titled "Verbal Orders, Physician Orders and Diagnostic/Lab Results", updated November 30, 2018, revealed "Upon receipt of a verbal diagnostic or laboratory test result, the nurse will document the results in PCC [Point Click Care-the facility's electronic medical record system] or appropriate form."
Review of Resident 1's clinical record revealed diagnoses that included congestive heart failure (CHF- a chronic condition where the heart cannot pump blood effectively, leading to fluid buildup in the lungs, legs, and other parts of the body) and hypertension (high blood pressure).
Review of Resident 1's physician orders revealed an order for labs dated March 8, 2025, for a CBC (complete blood count- a blood test used to look at overall health and find a wide range of conditions, including anemia, infection), a BMP (basic metabolic panel- a blood test that measures several important aspects of the blood, like electrolytes and blood sugar), and a urinalysis (urine test used to detect and manage a wide range of disorders, such as urinary tract infections [UTI], kidney disease, and diabetes).
Review of Resident 1's clinical record revealed documentation of the CBC results and the urinalysis results. Further review failed to reveal documentation of the BMP results.
Review of Resident 1's nursing progress note, written by Employee 1 (Licensed Practical Nurse) dated March 9, 2025, revealed that the CBC and the urinalysis results were received and reviewed and the provider was aware. Urinalysis results were positive for a UTI and the CBC showed a white blood cell count (WBC-help protect the body from infection) of 23.1 (normal is 3.9-9.5). Further review of the note failed to reveal any documentation regarding the BMP results.
During an interview with Employee 1 on March 24, 2025, at 12:46 PM, Employee 1 stated that on March 9, 2025, she called the lab to get the results. She stated that the lab notified her of the positive urinalysis, elevated WBC, and that the BMP was not viable, as there was not enough blood to run the test. Employee 1 stated that Resident 1's provider was beside her when she was on the phone with the lab and the provider was aware at that time that the BMP was not viable. Employee 1 stated that since Resident 1 was showing symptoms of an infection and the CBC and urinalysis showed an infection, the provider decided it wasn't necessary to redraw the BMP.
During an interview with Employee 2 (Physician) on March 24, 2025, at 1:09 PM, he stated that on March 8 and 9, 2025, the main concern for Resident 1 was infection, which was confirmed by the urinalysis and CBC. Employee 2 stated that because of the infection, there was no need to have to redraw the BMP at that time.
Review of Resident 1's clinical record revealed no documentation that Employee 1 notified the provider that the BMP was not viable and no documentation that the provider stated not to redraw the BMP.
During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on March 24, 2025, at 2:40 PM, the NHA stated he would expect Employee 1's conversation with the provider regarding Resident 1's BMP would be documented in Resident 1's clinical record.
28 Pa code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 05/12/2025
842
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
One: actions taken for situation identified:
1) The Facility recognizes that it cannot retroactively correct the situation for resident R1.
2) The Facility reviewed R1 for missing documentation
3) All current residents with lab orders since April 1, 2025 will be reviewed for incomplete documentation of missing or critical lab results and physician notification of same
Two: system changes and measures that will be taken:
1) All Licensed staff will be in-serviced on documentation accuracy for Provider notifications of missing or critical lab results
2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections
Three: monitoring mechanism to assure compliance:
1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance documentation, then five (5) random residents 1x week for 2 months.
2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings
|
|
